Provider Demographics
NPI:1225495211
Name:RUDDOCK, RESHA (APRN)
Entity Type:Individual
Prefix:
First Name:RESHA
Middle Name:
Last Name:RUDDOCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 W COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3300
Mailing Address - Country:US
Mailing Address - Phone:954-703-2931
Mailing Address - Fax:954-585-9207
Practice Address - Street 1:201 E SAMPLE RD
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-3502
Practice Address - Country:US
Practice Address - Phone:954-485-5666
Practice Address - Fax:954-484-1651
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9280554367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110096OtherNBCRNA